Sandy Hook, Violence and Mental Illness

n my last blog, I agreed to further discuss the topic of risk management. However that was before the tragic events in Sandy Hook. While discussing this event is still addressing the issue of risk, I’d really like to focus on the current debate regarding guns and the role of mental illness and violence.

The National Council and others have made the point repeatedly that people with serious mental illnesses are roughly two and a half times more likely to be the victims of violence than the perpetrators. The data suggests that only 4% of violent activities in the United States can be attributed to people who have a mental illness. That number is even less if you look at gun violence alone. During this debate, almost every public announcement, including those made by the NRA, has called for increased funding for mental health. If you’ve been in this business for very long, you know this industry is woefully underfunded so the call for increased funding should seem like a good thing.

I am worried this is a slippery slope. To simultaneously argue that the mentally ill are not the primary cause of violence and also request more funding for mental illness seems to be a mixed message at best. I could imagine the American public getting confused about the relationship between violence and mental illness. More importantly, this seems to deflect the discussion and, in doing so, calls attention to only a very small part of the problem. That is, if we could magically eliminate all of the violence due to mental illness, 96% of violence would still remain. Another problem with this argument is that once again there is no mention of the role of addiction and chemical dependency. Keep in mind, concurrent drugs and alcohol abuse do correlate with increased violence in people who have mental illness. Why does our culture continue to ignore substance use problems in this way?

Some argue one thing that could help is improved commitment laws, particularly for outpatient commitment. This is no panacea, but outpatient commitment has been shown to have a positive effect on treatment adherence particularly with medications. I suspect most of us have encountered a family member that is trying to get a loved one some help but being unable to do so. I can remember the frustration of having to tell parents of a young man who was experiencing his first psychotic episode that they would have to have him arrested to get treatment against his will. But, if he wasn’t a danger to himself or others, the police could not arrest him – making them powerless as well.

Even if someone wants treatment, they run the risk of a secure facility not being available. E Fuller Torrey has argued for an increase in the number of public psychiatric beds. Would that help? Perhaps, since by some estimates the number of beds has decreased by 95%.

At the time of this writing, President Obama just released his 23 executive orders to address the gun violence issue. One of these was to send a letter to healthcare providers reminding them “…no federal law prohibits them from reporting threats of violence to law enforcement authorities.” We will have to wait until these executive orders are clarified further; however, this particular recommendation does not seem too far removed from existing “duty to warn” requirements. So, this may not be a difference from what we are already accustomed to.

The mental health system we know is broken. All of the requirements referenced above would be helpful. But, in the big scheme of things, how much will this really help stem violence in the United States? Identifying the cause of violence and developing effective interventions is going to be one of the most difficult issues we face. Simple answers like banning guns are unrealistic and frankly, wrong. We have the second amendment and it is the law. More importantly, most people who own guns use them responsibly. Categorizing them otherwise is no more accurate than saying all mentally ill people are dangerous. From that perspective, mental health advocates have something in common with gun advocates — neither want our respective constituencies stereotyped by outliers. Yet the effects of gun violence in America cannot be ignored.

The Sandy Hook shootings may be the event that pushes us as a society to take action. Whether that action is real and substantive or just political grandstanding, time will tell. We live in a time when political rhetoric is not conducive to compromise and everyone wants a simple answer to a complex problem. These are difficult issues and mental health professionals need to be part of the solution.